Basic Information
| Provider Information | |||||||||
| NPI: | 1659798668 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUENTES | ||||||||
| FirstName: | MARIO | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7200 NW 7TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331262948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052646270 | ||||||||
| FaxNumber: | 3052617739 | ||||||||
| Practice Location | |||||||||
| Address1: | 8300 W FLAGLER ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331446002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055530270 | ||||||||
| FaxNumber: | 3055530670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2014 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | ACN600 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.